SEATTLE -- In suspected appendicitis, a CT scan can be well worth the wait before a patient goes to surgery, researchers here suggested.

Action Points

Explain to interested patients that the study found that CT imaging prevented many unnecessary appendectomies.

Explain that the findings were consistent with some earlier studies but not others that had found no benefit from routine CT imaging.

SEATTLE, Oct. 2 -- In suspected appendicitis, a CT scan can be well worth the wait before a patient goes to surgery, researchers here suggested.

In 100 patients evaluated for possible appendicitis in a suburban community hospital's emergency department, 29 had their initial treatment plans altered after CT imaging, reported Robert O. Nathan, M.D., of the University of Washington, and colleagues in the October issue of the American Journal of Roentgenology.

Treatment plans changed in about 60% of patients initially proposed for surgery, with 18 of 38 patients reassigned to discharge and four others to observation.

Moreover, among five patients who clinicians originally intended to observe, four were discharged and one was scheduled for surgical consultation after CT scans were reviewed.

But only two of 57 patients set to be discharged initially had their treatment plan intensified because of CT results.

"The data suggest that CT can be withheld in patients in whom emergency clinicians rate the likelihood of appendicitis as unlikely but that CT findings are often of benefit even when appendicitis is judged to be very likely," Dr. Nathan and colleagues wrote.

The researchers conducted a prospective study of consecutive adult cases at the 300-bed hospital over a four-month period in 2006.

Emergency physicians in this hospital routinely ordered CT scans for all patients with suspected appendicitis. No surgery was performed without CT results.

In addition to performing their standard patient evaluations, physicians also rated the likelihood of appendicitis in each case in five categories, from "unlikely" to "possible" to "equivocal" to "probable" to "very likely."

Nineteen patients had an appendectomy in the sample with appendicitis pathologist-confirmed in 17, including one patient with normal CT findings but clinical signs that persuaded the treating clinician to operate anyway.

In the other 81 patients, none had an appendectomy within two weeks of the initial emergency visit.

Among 20 patients classed as unlikely to have appendicitis in the initial evaluation, the condition was conclusively ruled out by CT in all cases.

CT findings ruled out appendicitis in nine of 18 patients with an initial judgment of "probable," and in three of five cases deemed to be "very likely."

"CT of the appendix has an important therapeutic impact in the evaluation of suspected appendicitis in a community hospital emergency department," Dr. Nathan and colleagues concluded.

They noted that some earlier research has yielded the opposite conclusion. For example, one study published in 2003 was titled, "Liberal Use of Computed Tomography Scanning Does Not Improve Diagnostic Accuracy in Appendicitis."

But, said Dr. Nathan and colleagues, "these studies were performed in either academic medical centers or community-based teaching hospitals in which surgical house staff members were readily available. Surgeons are less available in most community hospitals after hours."

At least two other studies in community hospital settings have found benefits from routine CT evaluation of suspected appendicitis, they said.

They said future research should focus on full cost-effectiveness analysis of CT imaging, including health-effects metrics.

No external funding for the study was reported.

No potential conflicts of interest were reported.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco

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